Clinical pharmacy

1. Clinical Pharmacy

2. Introduction to Clinical Pharmacy
• Definition: Clinical pharmacy is defined as the
branch of pharmaceutical science dealing with
utilization of pharmacist knowledge, skills and
judgments related to biomedical and
pharmaceutical sciences, to prove the safety,
the cost and the precision of the drug usage in
the patient care.

3. • Development of Clinical Pharmacy:
• In developed countries like United States of America.
Canada etc.
• Clinical Pharmacy has already taken good shape. In
India, it is in the infancy stage.
• The role of the retail pharmacist is viewed by many
people as simply transferring pills from a large bottle to
a small one - counting tablets, typing labels and
calculating the price.
• Much of his time is seen as devoted to routine
merchandising of cosmetics, skin, hair, dental products,
stationery and other commodities which have little or
no relation to health care.
• India stands among top fifteen in the world in
pharmaceutical market with respect to pharmaceutical
production, exports, imports etc.

4. • There is still a need to develop the concept of
clinical pharmacy.
• Today there is 'drug-explosion' and
'information explosion' in relation to the
drugs.
• On one hand there is development of newer
and more-effective drugs and on other hand
their potential hazards of side effects are on
rise.

5. • SCOPE OF CLINICAL PHARMACY:
• Clinical pharmacy has emerged as one of the
latest branches of pharmacy in 21st Century.
• It is where pharmacists deal with various
aspects of patient care, dispensing of drugs
and advising patients on the safe and rational
use of drugs.
• It can also be explained as a part of pharmacy
in which the clinical pharmacist provides
patient care that optimizes the use of
medication and promotes health, wellness,
and disease prevention.

6. • To elaborate the story we can say that clinical
pharmacy is to use drug control and the effective
application of the knowledge.
• Professional skills and ethics assure the optimal
safety in the distribution and use of medicine.
• The purpose of the Professional Education in
Clinical Pharmacy and Public Health is to qualify
each pharmaconomist (expert in
pharmaceuticals) to practice clinical pharmacy at
a higher and more professional level.
• Hence, ensures the patient’s maximum well-
being during the drug therapy.

7. • Clinical pharmacy describes the new role of the
21st Century’s pharmacists.
• It doesn’t restrict the role of a pharmacist merely
to good manufacture practices, easy
procurement, proper preparation, distribution
and control of drug products. In addition, it also
comprises functions necessary to discharge a
particular set of social responsibilities related to
proper therapeutic use of drugs in the aspects
like prescribing, dispensing and administrating
drugs, documenting professional services, direct
patient involvement, reviewing drug use,
education, consultation and counseling.

8. • The aim of clinical pharmacy practice is to ensure
the patient’s maximum well-being and to play a
meaningful role in the safe and rational use of the
drugs.
• These goals are to enable the physician do a
better job of prescribing and monitor the drug
therapy for patient. Further, to help the medical
and para-medical staff to enable effective drug
therapy.
• Clinical pharmacy practice also deals with proper
maintenance of the documentation regarding the
medication incidents effectively to maximize the
patient’s compliance in drug use process.

9. Qualities of clinical pharmacist
• Clinical pharmacists care for patients in all
health care settings but the clinical pharmacy
movement initially began inside hospitals and
clinics.
• Often collaborate with physicians and other
healthcare professionals.
• Pharmacists should be well- versed with the
common language used by the people in order
to communicate with the patient and co-
professionals easily and effectively.

10. • Pharmacists are also expected to have
thorough knowledge of the etiology of the
disease, its signs, symptoms, pathophysiology,
diagnostic tests, pharmacokinetics, etc.
• Proper clinical training should be given to the
clinical pharmacist to provide information
regarding rational drug use, drug therapy and
drug doses.

11. Condition for a clinical pharmacy
• A clinical pharmacy professional should
appreciate the role of medical and para-
medical staff.
• There should be enough bondage between
the physician and the pharmacist to visit the
patients together.
• All of the medical staff should develop an
inter- professional relationship to enhance the
quality of patient care.

12. • Further, there should be a deep sense of
responsibility in the clinical pharmacist with
respect to medical care.
• It helps in maintaining proper patient history
and gaining confidence.
• As drug therapy is an ongoing process it needs
to be checked by the clinical pharmacist
timely.
• It may be changed according to the patient’s
condition and requirement.

13. Health care team and a clinical pharmacist
• There are certain roles and responsibilities of
a clinical pharmacist in a health care team that
consists of several medical and para medical
professionals.
• These responsibilities should be executed by
the clinical pharmacist with immense care.
• The clinical pharmacist should interact with
the patients and maintain their complete and
exhaustible medical history.

14. • The clinical pharmacist should also do proper
documentation of the hypersensitivities or
allergy to certain drugs, food habits, drug
dependence or intoxications to certain
chemical substances, side effects of some
drugs, incorrect drug administration, etc
about the patient.
• The prescribed drugs may interact with certain
OTC drugs; therefore, after receiving the
prescription the clinical pharmacist should
check the patient’s medical history for drug
related interactions and patient’s habits.

15. • This helps in effective and accurate medical
therapy.
• In the selection of a proper drug product/generic
formulation (depending on the bio-availability
and equivalence of such products) the clinical
pharmacist can help the physician.
• Clinical pharmacist can help in monitoring of drug
therapy to ensure safety and efficacy.
• Monitoring of the drug therapy is very important
particularly for those drugs that have narrow
therapeutic index or administered chronically.

16. • Various pharmacokinetic parameters can also be
checked by the clinical pharmacist based on: plasma
concentration of drug, enzymes and measurement of
glucose quantity in blood, etc.
• Patients with kidney impairment or hepatic disorders
are more prone to adverse drug reactions.
• Clinical pharmacist can help in detection, prevention
and reporting of adverse drug reactions.
• He may advice the physician for alternate drug therapy
for the concerned patients.
• Clinical pharmacists may play a major role in designing
health and drug policies, and assist as a source of
information for the health care professionals and to
the public.

17. • The drug management greatly relies on the clinical
pharmacist to check the selection, requirement,
procurement, distribution and use of the drugs.
• Also, research and development in the field of
biological availability of active ingredients requires
active participation by the clinical pharmacists.
• The clinical pharmacist can help in executing clinical
trials and based on standard principles and bio-
statistical evaluation.
• A clinical pharmacist is an expert to provide detailed
information to the health professionals and the general
public.
• Effective selection, utilization and retrieval of drug
literature by the clinical pharmacist can enable in the
proper understanding of the facts by the medical team.
• He can also abstract information from periodic
bulletins, newsletters or other pharmacy literature.

18. Scope of clinical pharmacy in India
• In hospitals the services regarding clinical
pharmacy are of considerable value because
the concerned clinical pharmacist serves as a
guide to the physician for safe and rational use
of drugs.
• He also assists to achieve economy in the
hospital by planning safe drug policies,
suggestive means of reduction of waste, by
preventing misuse or pilferage of drugs.

19. • In addition to it the preparation of preventing
forecasting future drug requirements of the
hospital, based upon their drug utilization
patterns.
• Therefore, scope of clinical pharmacy covers
areas to foster innovation, improve public health
and provide a knowledge exchange.
• Clinical pharmacist enables rational drug use by
providing correct drug information including the
proper utilization of the drugs utilized as drug
therapy, along with all the precautions to be
taken as indicated or asked by the pharmacist or
the physician.

20. • It discourages any irrational or reckless use of
drugs and also, concerns with the procurement of
the drugs into the market from the industry and
their channelization to the patient for use.
• Clinical pharmacy also deals with ensuring safety
and efficacy of the drugs after marketing.
• Safety can be evaluated by means of non-
experimental research, whereas evaluation of
efficacy in a variety of settings representing
normal medical practice generally requires
experiments, randomized and blinded.

21. • National or International markets are flooded
with tens of drug combinations, low
therapeutic value products or duplicate brand
names.
• Thus, under this study it is clarified how to
choose the correct drug for administration or
treatment.

22. Functions and responsibilities of clinical
pharmacist
• Collection of patient data
• Identification of problems
• Establishing outcome goals through a good
therapeutic plan
• Evaluating treatment alternatives by
monitoring and modifying therapeutic plan
• Individualizing drug regimens
• Monitoring outcomes

23. COLLECTION OF PATIENT DATA:
– Demographics
– Current problems
– Past medical history
– Current medication
– Social habits
– Relevant laboratory data
– Subsequent modifications of therapy plan

24. IDENTIFICATION OF PROBLEMS:
• The data collected can be used to identify
actual or potential drug related problems.
– ACTUAL: A condition that requires the initiation of
a new or additional drug.
– POTENTIAL: The patient may be at risk to develop
a new medical problem.
• These problems may be related to the
patient’s current drug therapy, drug
administration, drug compliance, drug toxicity,
ADR’s and a failure to achieve desired
outcomes by the treatment.

25. ESTABLISHING OUTCOME GOALS:
• Drug therapy can produce positive outcome:
– Cure of the disease
– Elimination or reduction of patient’s
symptomology
– Arresting or slowing of a disease process
– Preventing a disease or symptoms
– It may also produce negative result, i.e. resulting
in disease morbidity and sometimes mortality.
•

26. EVALUATING TREATMENT ALTERNATIVES BY
MONITORING AND MODIFYING THERAPEUTIC
PLAN:
• Efficacy, safety, availability and cost of
treatment and suitability of the treatment to
the patient should be considered while
evaluating.
• The risk-benefit ratio factors should also be
considered: seriousness of the disease,
complications if untreated, efficacy of drug,
ADR’s.

27. INDIVIDUALISING DRUG REGIMENS:
• When more than one therapeutic alternatives
exist, the following factors to be considered:
– Patient factors:- diagnosis, treatment goals, past
medical and medication history, contraindication,
allergies, compliance
– Drug factors:- efficacy, adverse effects, dosage
form, cost, drug-drug interactions

28. MONITORING OUTCOMES:
• The goals are: Cure of the disease, elimination or
reduction of patient’s symptomology, arresting or
slowing of a disease process, preventing a disease or
symptoms.
• But often leads to suboptimal outcomes due to:-
inappropriate or unnecessary prescribing or drug
regimen, dispensing error, non-compliance,
inappropriate monitoring.
• To ensure good monitoring outcomes;
– Regularly should review whether satisfactory progression
is made or not according to the therapeutic plan.
– To determine whether original plan should continue or any
treatment modifications to be made or not.
– Reviews ongoing progress and provides report to patient’s
other healthcare providers. Should regularly update
patient’s medical/pharmacy records with information
concerning patient’s progress.

29. PHARMACEUTICAL CARE IN HOSPITALS:
– Prescription monitoring
– Prescribing advice to medical and nursing staff
– Medication errors and adverse reaction
monitoring
– Medication history interview
– Patient education and counselling
– Pharmacokinetics and therapeutic drug
monitoring Hospital formulary

30. PHARMACEUTICAL CARE FOR THE COMMUNITY:
– Participate in health screening
– Participate in health promotion and education
– Serve as a source of drug and poison information
– Collaborate with other health care professionals
to develop treatment guidelines
– Design and monitor procurement and drug
distribution system including storage and disposal.

31. DRUG THERAPY MONITORING
• Drug therapy monitoring, also known as
Therapeutic Drug Monitoring (TDM), is a means
of monitoring drug levels in the blood.
• Therapeutic drug monitoring (TDM) refers to the
measurement and interpretation of principally
blood or plasma drug concentration
measurements with the purpose of optimising a
patients drug therapy and clinical outcome while
minimising the risk of drug induced toxicity.
• TDM involves tailoring a dose regimen to an
individual patient by maintaining the plasma or
blood concentration within a particular range.

32. To achieve optimal drug therapy 3 objectives
should be met:
• To attain desired pharmacological effect of the
drug.
• To reach the maximal effect in shortest
possible time.
• To decrease the risk of toxicity.

33. TDM is useful in drugs:
• With a narrow therapeutic index.
• Which are highly protein bound.
• Which are liable to interact.
• In which the metabolite might be toxic.

34. • Drug therapy monitoring is an ongoing process in
which pharmacists actively review patients’
records, identify and resolve drug therapy
problems such as adverse drug events (ADEs),
and communicate with prescribers when
problems occur.
• Pharmacists educate patients and their
caregivers about potential adverse effects and
work with patients to ensure adherence to
therapy and attainment of therapeutic goals.

35. MEDICATION CHART REVIEW
• It is a fundamental responsibility of a pharmacist
to ensure the appropriateness of medication
orders.
• It serves as starting point for other clinical
pharmacy activities ( medication counselling,
TDM, DI, and ADR).
• Organizing information according to medical
problems ( example disease) helps breakdown a
complex situation into its individual parts.

36. GOALS:
• To optimize the patients drug therapy.
• To prevent or minimize drug related
problems/medication errors.
PROCEDURE:
• The patient's medical record should be reviewed in
conjugation with the medication administration record.
• Recent consultations, treatment plans and daily
progress should be taken into account when
determining the appropriateness of current medication
orders and planning each patient’s care.
• All current and recent medication orders should be
reviewed.

37. COMPONENTS OF MEDICATION ORDER REVIEW
include:
• Checking that medication order is written in
accordance with legal and local requirements.
• Ensuring that the medication order is
comprehensible and unambiguous, that
appropriate terminology is used and that drug
name are not abbreviated. Annotate the chart to
provide clarification as required.
• Detecting orders for medication to which the
patient may be hypersensitive/intolerant.

38. • Ensuring that medication order is appropriate
with respect to:
– The patient’s previous medication order.
– Patient’s specific considerations e.g disease state,
pregnancy.
– Drug dose and dosage schedule, especially with
respect to age, renal function, liver function.
– Route, dosage form and method of administration.
• Checking complete drug profile for medication
duplication, interactions or incompatibilities.
• Ensuring that administration times are
appropriate e.g. with respect to food , other
drugs and procedures.

39. • Checking the medication administration record to
ensure that all ordered have been administered.
• Ensuring that the drug administration order
clearly indicates the time at which drug
administration is to commence.
• special considerations should be given especially
in short course therapy as in antibiotics and
analgesics.
• Ensuring that the order is cancelled in all sections
of medication administration record when the
drug therapy is intended to cease.

40. • If appropriate follow up of any non-formulary
drug orders, recommending a formulary
equivalent if required.
• Ensuring appropriate therapy monitoring is
implemented.
• Ensuring that all necessary medication is
ordered. E.g. premedication, prophylaxis.
• Reviewing medication for cost effectiveness.

41. Identification of drug related problems.
• Untreated indication.
• Inappropriate drug selection.
• Sub therapeutic dose.
• Adverse drug reaction.
• Failure to receive drug.
• Drug interactions.
• Drug use without indication.
• Overdosage.

42. MEDICATION CHART ENDORSEMENT
• Another important goal of treatment chart
review is to minimise the risk of medication
errors that might occur at the level of prescribing
and / or drug administration.
• A medication error is any preventable error that
may lead to inappropriate medication use or
patient harm.
• To prevent potential morbidity and mortality
associated with these errors, pharmacists should
systematically review the medication chart and
write annotations on the chart where the
medication orders are unclear.

43. CLINICAL REVIEW:
• Clinical review is one of the integral components of
medication review and should preferably be performed
on a daily basis. It is the review of the patients’
progress for the purpose of assessing the therapeutic
outcome.
• The therapeutic goal for the specific disease should be
clearly identified before the review. GOALS:
The primary aims of the clinical review are to:
• Assess the response to drug treatment.
• Evaluate the safety of the treatment regimen.
• Assess the progress of the disease and the need for any
change in therapy.
• Assess the need for monitoring, if any.
• Assess the convenience of therapy(to improve
compliance).

44. PHARMACIST INTERVENTION
ROLE OF PHARMACIST
• A reliable and responsive TDM service
depends on team work between nurses,
doctors, pharmacist, scientist and technical
staff. The clinical pharmacist should provide
advice to medical staff on the appropriate use
and timing of TDM and assist with the
interpretation of results.

45. In addition the pharmacist maybe involved in :
• Initial selection of drug regimen: this may
involve decisions about drug choice, dose,
dosing interval, route of administration and
dosage form of the drug, taking into account
factors such as sex, age, body weight, race,
metabolism status, renal function, plasma
albumin concentration, use of other drugs and
laboratory results.

46. • Adjustment of the dosage regimen based on TDM
results and the patients clinical response.
• Assessment of possible causes for unexpected
results, such as non- compliance, bioavailability
problems, medication errors, drug interactions or
pharmacogenetic variability.
• Dose adjustment for patients on haemodialysis or
peritoneal dialysis.
• Provision of poisons information.

47. WARD ROUND PARTICIPATION
• A ward round is a visit made by a medical
practitioner, alone or with a team of health
professionals and medical students, to hospital
inpatients at their bedside to review and follow
up the progress in their health.
• Usually at least one ward round is conducted
every day to review the progress of each
inpatient, though more than one is not
uncommon.
• In certain practice settings such as psychiatry, the
“ward round” may be conducted away from the
patient’s bedside in a non-traditional fashion,
where the team meets elsewhere to review each
case.

48. Goals and objectives for clinical pharmacists on
ward rounds:
• As an important member of the healthcare
team, pharmacists should attend ward rounds
and clinical meetings whenever possible. This
enables pharmacists to contribute
prospectively to patient care through the
provision of drug therapy. The goals of a
clinical pharmacists participation in ward
rounds are to:

49. • Gain an improved understanding of patient’s clinical status
and progress, current planned investigations and
therapeutic goals.
• Provide relevant information on various aspects of the
patient’s drug therapy such as pharmacology,
pharmacokinetics, drug availability, cost, drug interactions
and adverse reactions.
• Optimize therapeutic management by influencing drug
therapy selection, implementation, monitoring and follow-
up.
• Investigate unusual drug orders or doses.
• Assimilate additional information about the patient such as
co-morbidities, medication compliance or alternative
medicine use that might be relevant to their management.
• Detect adverse drug reactions and drug interactions.
• Participate in patient discharge planning.

50. • Ward round participation also provides many
learning opportunities for pharmacists.
• It allows pharmacists to see firsthand how drugs
are used and prescribed and to see the effects of
these drugs on patients.
• With time, pharmacists develop an appreciation
of how the patient’s own wishes and their social,
cultural and economic circumstances may
influence therapeutic choices.
• Even for experienced clinical pharmacists in
teaching hospitals, it is very rare to finish a ward
round without gaining new perspectives on some
aspect of therapeutics or patient care.

51. • For those involved in academia and research,
ward rounds allow identification of cases for
clinical teaching and publication.
• Not the least, ward round participation
strengthens the inter-professional relationship
among various health professionals, leading to
better healthcare practice and research.

52. MEDICATION HISTORY
• A medication history is a detailed , accurate and
complete account of all prescribed and non-
prescribed medications that a patient had taken
or is currently taking prior to a initially
institutionalized or ambulatory care .
• It provides valuable insights in to patient’s allergic
tendencies , adherence to pharmacological and
non-pharmacological treatments and self
medication with complementary and alternative
medicines .
• Interviewing a patient in collecting the data
medical history is called medication history
interview.

53. Importance of accurate drug history
• Preventing prescription errors and consequent
risk to patients.
• Useful in detecting drug –related pathology or
changes in clinical signs that may be the result
of drug therapy.
• It should encompass all currently and recently
prescribed drugs, previous adverse drug
reactions including herbal or alternative
medicines and adherence to therapy for
better care plan.

54. Goals
• The goal of medication history interview is to
obtain information on aspects of drug use that
may assist in over all care of patient . The
information collected can be utilized to :
1.Compare medication profile with the
medication administration record and investigate
the discrepancies .
2.Verify medication history taken by other staffs
and provide additional information where
appropriate.

55. The following information is commonly recorded:
• Currently or recently prescribed medicines
• OTC medication
• Vaccinations
• Alternative or traditional remedies
• Description of reactions and allergies to medicine
• Medicines found to be ineffective
• Adherence to past treatment and the use of
adherence aids

56. Information sources
• Patient
• Family or caregiver
• Medication vials / bubble packs
• Medication list
• Community pharmacy
• DPIN (Drug programs information network)

57. Question to Ask
• Which community pharmacy do you use?
• Any allergies to medications and what was the reaction
?
• Which medications are you currently taking:
• The name of the medication
• The dosage form
• The amount (specifically the dose)
• How are the taking it(by which route)
• How many times a day
• For what reason

58. • What prescription medications are you taking on a regular basis or
as needed basis?
• What over the counter medications are you taking on a regular or
as needed basis?
• What herbal or natural medicines are you taking on a regular or as
needed basis?
• What vitamins or other supplement are you taking?
• Have you recently started any new medicines?
• Did a doctor change the dose or stop any of your medications
recently?
• Did you change the dose or stopped any of your medications
recently?
• Are any of the medications causing side effects
• Have you change the dose or stopped any medications because of
unwanted effects ?
• Do you sometimes stop taking your medicine whenever you feel
better?
• Do you stop taking your medicine if it makes you feel worse?

59. Pharmaceutical Care
• Pharmaceutical Care is a patient-centered,
outcomes oriented pharmacy practice that
requires the pharmacist to work in concert with
the patient and the patient's other healthcare
providers to promote health, to prevent disease,
and to assess, monitor, initiate, and modify
medication use to assure that drug therapy
regimens are safe and effective.

60. The goal of Pharmaceutical Care is to optimize the
patient's health-related quality of life, and
achieve positive clinical outcomes.
• A structured approach to achieve these goals:
– It requires an established patient-to pharmacist
relationship.
– It requires records of medication to be kept and, with
the patient’s informed consent, additional patient
specific information to be collected, organized,
recorded, monitored and maintained.
– It requires patient-specific medical information to be
evaluated and, in the case of prescribed medicines, a
therapy plan to be developed involving the patient
and the prescriber.

61. – It requires the pharmacist to ensure that the patient
has all supplies, information, and knowledge,
necessary to carry out the drug therapy plan.
– It requires the pharmacist to review, monitor, and
modify the therapeutic plan in concert with the
patient and healthcare team.
Elements to provide quality pharmaceutical care
are:
• Knowledge and skills of personnel,
• Systems for data collection, documentation, and transfer of
information,
• Efficient workflow processes,
• References, resources and equipment,
• Communication skills,
• Commitment to quality improvement and assessment
procedures.